Is Toby headed for Washington? Just maybe.

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Cleveland Clinic CEO Dr. Toby Cosgrove

Cleveland Clinic CEO Dr. Toby Cosgrove has emerged as
Donald Trump's favorite to lead the troubled Department of
Veterans Affairs. It's not terribly surprising given that
President Barack Obama considered Cosgrove for the role in 2014.
At the time, it wasn't the right fit. But this time around we
could see Cosgrove, who without question is one of the most
powerful figures in Northeast Ohio's civic circles, taking the
job. Here's why.

It's not terribly surprising given that President Barack Obama considered Cosgrove — a decorated Vietnam veteran who has a demonstrated commitment to those who served — for the role in 2014. At the time, it wasn't the right fit for the prolific heart surgeon and he withdrew his name from consideration.

That in mind, this time around we could see Cosgrove, 75, who without question is one of the most powerful figures in Northeast Ohio's civic circles, take the job. Here's why:

The Trump card

It's no secret the President-elect is seeking out outsiders to flesh out his administration. He's tapped the Exxon Mobil CEO to be his secretary of state, for example, and a big-time fast-food executive to lead the labor department. Cosgrove's business acumen, particularly his astuteness in streamlining complex bureaucracies (OK, maybe the Clinic's billing department still needs some work) could be useful in transforming the troubled VA department.

For example, Cosgrove has been instrumental in the development of so-called Care Paths at the Clinic. Earlier this year, Crain's health care writer Lydia Coutré reported the Clinic put together 125 guides and 37 pilots to increase efficiencies in treating certain conditions. These Care Paths helped reduce the cost of total knee replacement by 16% between 2013 and 2015, dropping from $3,600 to $3,000. That's the sort of ingenuity Trump could use at the VA, a massive agency with facilities all over the country, that for years has been criticized for long wait times for care at its facilities over concerns about its quality of care.

And from Cosgrove's perspective, now could be an opportune time to join the agency. When Obama considered Cosgrove in 2014, the president, by most accounts, was already a lame duck in the sunset of his presidency with an uncooperative legislative branch. Joining a Trump administration at its start with a Republican-controlled legislative branch would allow Cosgrove to enact some meaningful change. Having been the Clinic's CEO since 2004, his tenure is already longer than the typical hospital CEO. He's always been in it for the long haul.

Cosgrove, like the president-elect to a degree, has made a few off-kilter statements. Several years ago, he told The New York Times that, if it were legal, he wouldn't hire obese people. That's the sort of honesty that could endear him to Trump and an inner circle that loathes political correctness. Of course, the President-elect is a known fast-food connoisseur, so I'm not sure how Cosgrove's almost decade-long crusade to rid the Clinic's main campus of its McDonald's will go over.

His legacy is intact

When Cosgrove pulled himself out of the running for the VA post in 2014, he said it was "due to the commitment I have made to the organization, our patients and the work that still needs to be done here."

At the time, the Clinic was still in the midst of several major expansion projects. For one, the hospital was putting the finishing touches on its hospital in Abu Dhabi — a 364-bed, 2.6 million-square-foot luxury hospital the Clinic agreed to manage on Al Maryah Island. It was plotting a new hospital in the western suburb of Avon, exploring a takeover of Akron General and figuring out the scope of its new affiliation with the Case Western Reserve University School of Medicine.

For the most part, all of those promises have been delivered upon aside from the physical manifestation of that medical school initiative — a 485,000-square-foot, $515 million Health Education Campus that will eventually rise on East 93rd Street between Euclid and Chester avenues near the Clinic's main campus.

Over the last decade, Cosgrove has played an important role in the Clinic's rapid expansion in the region, across the country and even around the world. It's fair to say that his legacy is pretty well cemented. Anything else he accomplishes is only gravy.

It's worth noting that in 2015, the health system, in Cosgrove's own words, had "the best financial year that the Cleveland Clinic has ever had." Since then, the financial picture's gotten a bit cloudier, which hospital officials chalk up to the fact that inflation in operating expenses is outpacing reimbursement rates.

And if you still need a stocking stuffer or want to familiarize yourself with some of Cosgrove's work, his book, "The Cleveland Clinic Way" is available on Amazon for a cool $24.28 (free two-day shipping for Prime members!).

Successor in place?

During the last go-around, speculation swirled who might take over for Cosgrove were he take on the VA post. At the time, insiders and local health care observers, who acknowledged the Clinic tends to promote from within its own ranks, pointed to Brian Donley, Marc Harrison, Tomislav Mihaljevic, David Bronson or Jeffrey Ponsky as physicians who would vie for the role. Harrison, then the head of the Abu Dhabi project, has since left the Clinic for Intermountain Healthcare in Salt Lake City. Bronson has inched into retirement, having added emeritus to his title, according to his LinkedIn profile. The rest remain at the Clinic, though Donley's star still appears to be rising the fastest.

Donley, a well regarded orthopedic surgeon known for also being a top-notch administrator, has served as the Clinic's chief of staff since 2015. Donley has taken on a particularly public facing approach to the role (he's even been spotted in Clinic commercials). If Cosgrove leaves, my money's on this guy taking the top job (with Cosgrove's blessing).

Timothy Magaw covered health care for Crain's for five years before becoming sections editor. He frequently tweets about health care, fatherhood, Pearl Jam and Northeast Ohio's business happenings.